- CONDITION CENTERS
Dr. Bartholow is a clinical pharmacist at VA Southern Nevada Healthcare System in Las Vegas, Nevada. Dr. Muzyk is a freelance clinical pharmacy writer based in Tampa, Florida.
Schizophrenia is a complex mental disorder characterized by recurrent episodes of psychosis and a continuing decline in functional capacity.1 Roughly 90% of patients treated for schizophrenia are between 15 and 55 years old, as onset before age 10 or after age 60 is extremely rare. An equal prevalence is present in men and women, although onset usually occurs earlier in men (8-25 years) than in women (25-35 years).2
Early-onset schizophrenia (18 years or younger) accounts for up to one third of schizophrenic patients.3 Unlike adult-onset schizophrenia, which is characterized by an initial period of acute psychotic episodes mixed with more stable periods of considerable improvement, adolescents with schizophrenia generally exhibit more subtle symptoms and chronic, less pronounced periods of psychoses. These patients generally have fewer periods of recovery and have worse outcomes than adult-onset patients.4,5
Symptoms of Schizophrenia
Symptoms of schizophrenia fall into 2 categories. Positive symptoms, or psychosis, include hallucinations (false perceptions), delusions (false beliefs), and disorganized thoughts and behavior.6 Negative symptoms include constricted or blunted affect, poverty of speech or speech content, poor grooming, lack of motivation, and social withdrawal.2 None of these symptoms, however, are exclusive to schizophrenia. Diagnosis of early-onset schizophrenia must take into account medical and mental health history, family history, and alternative causes of the symptoms.6 Metabolic disorders, central nervous system injury, infections, adverse drug reactions, and epileptic disorders can result in symptoms of altered mental status, hallucinations, and psychosis.6-12 Other psychiatric conditions, such as schizoaffective, personality, and mood disorders, must also be ruled out.6 Table 113 presents the diagnostic criteria for schizophrenia from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
The design of the treatment plan must be based on the patient’s diagnosis, symptoms, medical history, and living conditions.14 Providers must work with family and caregivers to determine the best treatment options. A relationship with the patient should be established on a foundation of trust, communication, confidentiality, and respect.15 Although parents or guardians can legally consent to treatment on behalf of their child, gaining the patient’s consent may reduce his or her resistance to medical care. Patients need to be educated about their therapy, and their concerns should be addressed. As therapy progresses, the treatment plan must be routinely reassessed for optimal outcomes. Several pharmacologic agents have been studied in the treatment of earlyonset schizophrenia. First-generation antipsychotics (typical antipsychotics) and second-generation antipsychotics (atypical antipsychotics) have been shown to improve symptoms in earlyonset schizophrenia.16,17 (Table 2 presents examples of both types of antipsychotic agents.)
Fewer cases of extrapyramidal symptoms and tardive dyskinesia have been reported with the atypical antipsychotics; thus, it may be preferable to initiate treatment with an atypical agent. Weight dyscrasias and metabolic disturbances are of concern with the use of atypical antipsychotics and should be monitored closely.18-20 Once an antipsychotic agent is initiated and titrated to an optimal therapeutic dose, a trial period of 4 to 6 weeks is necessary to adequately determine therapeutic efficacy. If a sufficient response is not achieved, or if intolerable side effects are encountered, a different agent may be tried. Due to the risk of side effects and the need for intensive monitoring, clozapine is typically not used unless treatment failure occurs with at least 2 other agents.
It is important to recognize the physiologic differences that may impact antipsychotic therapy in children and adolescents. Drug metabolism and distribution in this population is markedly different than in adults. Children generally have significantly lower body fat percentages, increased extracellular water volume, and a proportionally greater rate of hepatic metabolism relative to body weight. It is postulated that children require a higher weight-adjusted dose to achieve similar plasma levels and therapeutic effects; however, specific pharmacodynamic and pharmacokinetic data on the use of antipsychotics in children and adolescents is limited. The risk of toxicity is a concern, and patients must be monitored closely.
Nonpharmacologic options work synergistically with pharmacotherapy to help patients develop the social and personal skills necessary for independent living.2 Options include social skills training, cognitive behavioral therapy, group therapy, and individualized counseling. Psychotherapy must be individually tailored to meet the needs of the patient. Additionally, family counseling, parent management training, and special education programs can strengthen the patient’s primary support system and living environment, thereby improving adherence and maximizing therapeutic benefits.